PUBLIC HEALTH.

Public health refers to the science and practice of protecting and improving the health of a community through a variety of means, including preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of the environment.

Although the sanitary movement of the mid-nineteenth century helped to lower death rates from enteric diseases, particularly cholera, epidemic disease remained commonplace throughout an increasingly industrialized Europe. Scholars therefore trace the modern era of public health in Europe to the late-nineteenth-century "bacteriological revolution" and to broader contemporary health programs initiated by state governments as they took shape during the last quarter of the nineteenth century. At the root of these programs was the realization among state leaders that proper maintenance of public health could help ensure social stability, prosperity, and order. Indeed, better public health could help to make healthier and therefore more productive citizens. The tension that existed in this rationale—namely the exercise of government authority to achieve community health, on the one hand, and the restriction of individual rights, on the other hand—is a recurring theme in the history of modern European public health programs, and it informs issues of public health in early-twenty-first-century Europe.

THE "BACTERIOLOGICAL REVOLUTION"

Led by the research of two scientific rivals—Louis Pasteur (1822–1895) in France and Robert Koch (1843–1910) in Germany—the emerging sciences of microbiology and immunology paved the way to substantial changes in thinking about the cause and transmission of disease.

Until the 1880s, the miasma theory of disease prevailed in scientific circles. This theory held that diseases such as cholera were caused by a noxious form of miasma, a term meaning "bad air," derived from the Greek word for "pollution." Through the therapeutic research of Pasteur and the bacteriological research of Koch, the germ theory of disease took shape, advancing the claim that microorganisms may be the cause of disease. Further breakthroughs by Koch, by his assistants Friedrich Loeffler (1852–1915) and Georg Gaffky (1850–1918), and by others who used Koch's methods of cultivating and isolating bacteria yielded identification of the bacteria responsible for diphtheria, typhoid, tetanus, and cholera. Such efforts, combined with further scientific and technical advancements, led to the introduction of the first generation of vaccines for use in humans, including those for rabies (1885), plague (1897), diphtheria (1923), pertussis (1926), tuberculosis (1927), tetanus (1927), and yellow fever (1935). Bacteriology also opened the door to better disease control among infected populations. State public health policies had long implemented quarantines and isolation to control the spread of disease. But with the advent of greater knowledge of disease-causing bacteria, authorities could exact a more targeted response to a disease outbreak, whether among travelers in rural areas or populations in dense urban centers.

The "bacteriological revolution" yielded a reaction that became integral to the further development of public health in Europe through the first two decades of the twentieth century. Even as deaths from infectious disease declined, deplorable health conditions remained for the working classes and urban poor. Contemporary commentators found the germ theory by itself to be insufficient in the promotion of better public health. Increasingly, socialists and radical physicians questioned the value of leaving community health to scientific thinking alone. Greater social measures, they claimed, such as improved diet, safe and hygienic living and working conditions, and health education, would prove equally if not more beneficial to improving community health. Across Europe, state governments and local municipalities reacted by initiating a variety of public health measures that sought not only to improve public welfare but also to protect and enhance government authority. Reform-minded voluntary health agencies joined the effort by reacting to the perceived failure of public leaders to address deplorable conditions among the working classes. As responsibility for the health of the public shifted from the individual to the government, such responsibility became a matter of politics and, therefore, an entitlement of citizenship.

THE RISE OF SOCIAL MEDICINE

The period from 1914 to 1918 and the decades following the "war to end all wars" mark complex chapters in the history of public health in Europe. Although social medicine was already under way before the war as a means to ameliorate various causes of poor health—or, in some cases, the perceived causes of poor health—it grew significantly from wartime experience and yielded uneven results across nations. Among the many conditions addressed in a variety of ways were infant mortality and maternal welfare, venereal disease and prostitution, and poor working conditions.

During the first two decades of the twentieth century, ubiquitous rates of infant mortality became major threats to public health. Child and maternal health programs therefore emphasized nutrition to counterbalance malnourishment, health education and inspection to correct parental ignorance and school environments, and hygiene to eliminate contaminated food. The pronatalist campaign emerged in France, while across Britain voluntary and local government sanitary societies taught hygiene to children. In Germany, Czechoslovakia, Russia, and Italy schoolteachers taught children games, drills, and gymnastic exercises as means to stay healthy. Significantly, German concerns about the broader implications of child and maternal health, and no less reproductive hygiene, took on new meaning during the 1930s as Adolf Hitler radicalized what had earlier been a relatively moderate national eugenics movement. In Nazi hands, positive eugenics became a means to achieve a "pure" German race. "Racial hygiene" programs of the Third Reich included awards to "Aryan" women who had large numbers of children. These programs also involved impregnation of "racially pure" single women by members of the Schutzstaffel (SS), which formed the basis of the Nazi police state and was the major instrument of racial terror in the concentration camps and occupied Europe.

The interwar period also saw negative eugenics become a means to address concerns about child and maternal health and no less the health of the nation. Following its establishment in 1922, Sweden's National Institute for Race Biology sponsored research in social engineering that ultimately led to the forced sterilization of an estimated sixty thousand "unfit" men and women between 1936 and 1976. While Nazi eugenics programs offered rewards to certain people, they also involved forced sterilization of hundreds of thousands of men and women who were viewed as mentally and physically "unfit," compulsory "euthanasia" programs that killed tens of thousands of institutionalized individuals with disabilities, and the systematic killing during the Holocaust of millions of "undesirable" Europeans including Jews, Gypsies, and homosexuals. Such programs existed alongside extensive experimentation on live human beings to test Nazi genetic theories, ranging from simple measurement of physical characteristics to horrific experiments carried out in concentration camps.

Contemporaries also understood that venereal disease and prostitution threatened public health, especially during World War I. From 1914 through the demobilizations that extended into the early 1920s, military authorities of the major combatant nations used education and official entertainment as means to keep their soldiers away from liquor and local prostitutes, and therefore fit for service. In Britain, voluntary-aid organizations such as the YMCA and Salvation Army assisted in this effort by establishing distinctive "rest huts" on the home front and overseas where soldiers could enjoy hot drinks, hearty meals, and the company of "motherly" women volunteers. Based in part on prewar efforts to ameliorate living conditions of the urban poor, these "homes away from home" were intended to help preserve men not only for battle but also for postwar life as husbands and fathers. After the war, such efforts to promote abstinence gave way to a pragmatic acceptance that distributing condoms was a more effective means of controlling venereal disease.

Following World War I, poor working conditions and the poor health of laborers were also identified as threats to public health. This concern was perhaps most evident in the establishment of the International Labour Organization (ILO) in 1919 through the negotiations of the Treaty of Versailles. Adopted by the Paris Peace Conference in April 1919, the constitution of the ILO stated plainly that "conditions of labour exist involving such injustice hardship and privation to large numbers of people as to produce unrest so great that the peace and harmony of the world are imperiled." Politics and economy certainly drove the mission of the ILO, but so too did health and welfare. "The solemn obligation of the International Labour Organization," as its constitution concluded, was to "further among the nations of the world programmes which will achieve … adequate protection for the life and health of workers in all occupations; provision for child welfare and maternity protection; … [and] the provision of adequate nutrition, housing and facilities for recreation and culture."

POSTWAR EUROPE

Across Europe after World War II, spending on all aspects of public health increased in real terms as government leaders held that economic growth could emerge through welfare state programs that made citizens healthier and better educated. West Germany's welfare model took shape from roots in the late-nineteenth-century Bismarck Era, while France's social security system emerged from conservative politics and Britain's National Health Service did so from the Labour government and its minister of health from 1945 to 1951, Aneurin Bevan. The hopes of the future did not come to pass, however. Even as the rates of infectious diseases and infant and child mortality in Europe reached unprecedented lows, economic growth slowed, making public health and medical programs more difficult to finance. Poverty, unemployment, and a host of new conditions placed increasing demands on welfare states. By the late 1960s, the purview of public health in Europe, and no less in industrialized nations around the world, had expanded to encompass chronic diseases (such as heart disease and cancer) and their causes (such as smoking), aging populations, disparities in health (because of race, ethnicity, gender, and occupation), obesity, and domestic violence. European state intervention in public health grew through the mid-1970s when economic crises of that decade required unprecedented cuts in public spending. Critics of the welfare state at this time claimed that its attempt to "provide for all" revealed a substantial failure to discriminate in favor of those in greatest need. This failure, critics argued further, had created a culture of dependency.

NEW CHALLENGES

In 2000 the European Commission issued the first coherent and coordinated strategy for a Europe-wide public health strategy. Adopted formally by the European Union in 2002, the program indicated three priority objectives: to improve information and knowledge for the development of public health; to enhance the capability of responding rapidly and in a coordinated fashion to threats to health; and to promote health and prevent disease by addressing health determinants across all policies and activities.

The commission's strategy, alongside those of individual European nations, helps illuminate the variety of public health priorities facing Europe in the twenty-first century. The foremost among these is how best to recalibrate the welfare state commensurate with promises of freedom and security, with economic and political constraints driven by European unification and interdependence, with the market forces unleashed by globalization, and, to be sure, with new, emerging, and changing threats to public health such as influenza, severe acute respiratory syndrome (SARS), West Nile virus, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

RECENT SCHOLARLY INTERPRETATIONS AND DEBATES

First published in 1958 and updated and expanded in 1993, George Rosen's A History of Public Health documents health regulation in Western societies from ancient Greece to the modern United States. It is a standard text that should be read by anyone who wishes to know more about the history of public health and understand recent scholarly interpretations and debates. Rosen's story is a chronological account of social progress arising chiefly from the technological advance of science and medicine in combating endemic and epidemic diseases. The growth of public health, Rosen argued, paralleled the rise of centralized government and was the result of scientific and medical knowledge triumphing over ignorance.

In the 1970s and 1980s, however, scholars substantially challenged the heroic interpretation of public health progress held by Rosen and his contemporaries. In his book The Modern Rise of Population (1976), Thomas McKeown agreed that modern medicine and public health had relieved suffering, but he argued that the decline of epidemic diseases, and especially those that affected children and young adults, stemmed not from the outcome of triumphant state medicine and public health programs but rather from better immunity resulting from better nutrition. In his book The Great War and the British People, first published in 1986 and revised in 2003, J. M. Winter advanced the paradox that while World War I and the mobilization of British society brought with it unprecedented slaughter, it was an occasion of substantial improvement in the life of the civilian population of Britain. Munitions canteens made food easily available to the nearly one million workers in munitions factories, rates of infant mortality declined, and rationing resulted in the healthy developments of scarcer alcohol; weaker beer; less consumption of sugar, butter, and meat; and more of consumption of bread and potatoes. Winter's book is a landmark study that deserves attention by anyone interested in wartime health, regardless of time period.

The 1980s and 1990s saw further challenges to and modifications of Rosen's interpretation. These new arguments were based largely on views of public health programs as instruments of social control through which elite society protected its power rather than emancipated the underprivileged classes from conditions that caused disease, famine, and poverty. Michel Foucault, for example, identified repressive discipline emerging from the centralized state and its clinics and hospitals. Other scholars of this period, including David Armstrong and Bryan S. Turner, recognized more broadly the inevitable tension that arises in the power of the expanding regulatory state, between individual civil liberties, on the one hand, and the collective needs of the community, on the other hand. Recent scholarship in the field, including work by Daniel Kevles, Paul Weindling, and others, has explored this tension in a variety of contexts, including eugenics, a case in which they show how rational and comprehensive public health planning can yield murderous public policy rather than freedom from disease and suffering.

Other scholars have revealed further complexities in the history of public health that depart substantially from Rosen's view. For example, no longer do historians see public health programs as being emblematic of or the result of centralized industrial government. In Germany, France, and elsewhere, local governments have at times exerted substantial local autonomy in matters of public health. Local studies, therefore, have been integral to recent scholarship, but so too have been projects that examine global public health, such as the new, emerging, and changing threats described above, and international agencies, such as the World Health Organization, that have attempted to work both within and across nations to achieve for all peoples the highest possible levels of physical, mental, and social well-being.

See alsoBevan, Aneurin; Eugenics; Welfare State.

BIBLIOGRAPHY

Armstrong, David. Political Anatomy of the Body: Medical Knowledge in Britain in the Twentieth Century. Cambridge, U.K., 1983.

Brown, Theodore M., Marcos Cueto, and Elizabeth Fee. "The World Health Organization and the Transition from 'International' to 'Global' Public Health."American Journal of Public Health 96, no. 1 (2006): 62–72.

Brunton, Deborah, ed. Medicine Transformed: Health, Disease, and Society in Europe, 1800–1930. Manchester, U.K., 2004.

Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. Translated by A. M. Sheridan Smith. New York, 1973. Reprint, New York, 1994.

McKeown, Thomas. The Modern Rise of Population. London, 1976.

Porter, Dorothy. Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times. London, 1999.

Porter, Dorothy, ed. The History of Public Health and the Modern State. Amsterdam, 1994.

Rosen, George. A History of Public Health. Expanded ed. Baltimore, 1993.

Sigerist, Henry. Landmarks in the History of Hygiene. London, 1956.

Turner, Bryan S., with Colin Samson. Medical Power and Social Knowledge. 2nd ed. London, 1995.

Weindling, Paul. Health, Race, and German Politics between National Unification and Nazism, 1870–1945. Cambridge, U.K., 1989.

Winter, J. M. The Great War and the British People. 2nd ed. Houndmills, Basingstoke, U.K., 2003.

Jeffrey S. Reznick